THE NEW INDIA ASSURANCE COMPANY LIMITED
Regd. Office: New India Building, 87, Mahatma Gandhi Road, Fort, Mumbai-400001
Mobile Handsets Insurance Claim Form
Please note: - The issue of this claim form is not to be taken as an admission of liability. All columns need to be filled up in detail in all respect.
Note: (*) and (*#) mark field implies mandatory fields, need to be filled in detail compulsorily or else the document shall be treated as incomplete.
In case of incomplete document/details claim will be void.
DETAILS OF THE INSURED/BENEFICIARY
M/s. NSI Infinium Global Limited
*Store Name:
Store Location
Date of Purchase
*Name of Customer/Purchaser:
DD/MM/YY
(please write complete name
including father/ mother/ spouse
name, etc as applicable)
*Address Line 1:
*Address of Customer/Purchaser:
(Note - Provide your reachable or present
address on which any
*Address Line 2:
correspondence if required, can be sent)
*City
*Pin code:
*State:
CONTACT DETAILS OF CLAIMANT/BENEFICIARY
Landline No:
STD code
Any other relevant information:
*#Currently in use reachable 10 digit Mobile Contact no:
Alternative contact no:
Email Id:
*# - Provide your currently in use reachable 10 digit Mobile contact no. which will be used for all your claim & information related communication purpose.
EQUIPMENT DETAILS:
*Make:
*Model:
DD/MM/YYYY
*Purchase Date:
*Purchase Invoice No:
*IMEI no / Serial no (as mentioned in your INVOICE/BOX): 1)
2)
Type of Equipment:(Handset/laptop/Phablet/Tablet)
DETAILS OF LOSS
Please enter relevant information according to the nature of your claim i.e. (Theft/Burglary/ Damage)
H
M
M
DD/MM/YYYY
Time of loss: H
*Date of Loss/Damage:
*Type of loss:
Theft
*Brief description of incident of
loss:
Is there any other insurance
cover for this equipment, if
yes then please provide
entire detail:
(If the space is insufficient use a
separate sheet & attach)
*Estimate of loss:
INR:
Provide Intimation number, if reported through web or call:
*To be filled in case of Theft claims
*Police Station, where the matter have been reported:
*Police Reference
No:
*10 digit Mobile number used at the time of loss:
(*Applicable only for Mobile Handset)
Type of SIM tariff (Prepaid/ Postpaid connection):
(*Applicable only for Mobile Handset)
Letter for barring SIM services given to Network Provider (YES/NO):
(*Applicable only for Mobile Handset)
*SIM Network
Service
If YES Please give date of
submission:
DD/MM/YYYY
Declaration
I/We agree to provide additional information to the company, if required. I/We the above mentioned, do hereby, to the best of my/our knowledge and belief, warrant
the truth of the foregoing statement in every respect & if I/We have made, or in any further declaration the company may require in respect of the said loss, shall
make any false or fraudulent statement, or any suppression or concealment, the policy shall be void and all rights to recover there under in respect of reimbursement
shall be forfeited.
Date:
Place:
Signature of Insured Person/Beneficiary
Attach a copy of Photo ID - cum - signature proof
Declaration Form – Theft Claim
Date: …...... /...…….. / 20…
From,
Mr. / Ms.
(Claimant Name)
Address Line 1:
Address Line 2:
City/District:
Street Name:
Pin code:
State:
To,
The New India Assurance Co. Ltd
87, M. G. Road, Fort, Mumbai – 400001
I/We Mr. / Ms. ………………………………………………………….would hereby like to inform that I/We
had purchased the insured equipment from M/s. NSI Infinium Global Limited, vide Invoice
No……..…………..………………………… Dated……/……/20…..
Type of Equipment:
*Bearing IMEI No.1)
*Bearing IMEI No.2)
Make
& Model No. as
and the said equipment have been lost/damaged on
dated ….……/….……/20……., detailed description of loss/damage is as mentioned below.
Detail Description of Incidence of loss/damage:
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
In connection to the aforementioned loss, I would hereby like to assign, transfer my authority to The New India
Assurance Co. Ltd, 87, M.G. Road, Fort, Mumbai – 400001 for the said equipment.
I/We agree to submit the salvage in case the claim is approved for total loss. I/W e have read all the above
mentioned information and I accept the same in totality and the same are true to the best of my/our
knowledge. I/W e hereby abide the terms and conditions of the policy.
Thanking you,
Name & Signature of the Claimant/Insured:
Date: ………/……….. / 20……
To,
Customer Service Manager,
………………………………………….
………………………………………….
………………………………………….
Reg.: Barring SIM Services of Mobile No: (*Applicable only for Mobile handsets/Tablet/Phablet with SIM)
Dear Sir/Madam,
This is to inform you that Mobile No:_________________________________________________ is in the name of
___________________________________________________________________& address registered with you
is__________________________________________________________________________________________
& I/We was using the (prepaid/postpaid SIM connection)_____________________________________________.
I/We would hereby like to inform you that my mobile along with the SIM for the no________________________
have been lost / stolen on ………/………/201…..
Accordingly I / we would hereby request you to kindly bar the incoming and outgoing calls & all related
services for the said number.
Please do the needful and bar the calls on receipt of the said letter. I / we would further request you to
kindly let us know your reference no. for aforementioned request along with new SIM no.
Your Ref. No.:________________________________
New SIM no.: ___________________________________________________________ (Mentioned on the backside
of the New SIM package issued)
Thanking you,
Signature & Address of Claimant/SIM Owner
Seal & Signature of Service Provider
Date:
Place:
Date:
Place:
Authorized Signatory Name of SIM Service Provider:________________________
To,
Police Station In charge
-------------------------------------------------------------------------------------------
Date:
Reg.: Lodging a complaint against equipment bearing IMEI/Serial No.___________________
Dear Sir,
I/We Mr. / Ms. ………………………………………………………….would hereby like to inform that I/We had purchased
insured equipment from M/s. NSI Infinium Global Limited, vide Invoice No……..…………..…………………………
Dated……/……/20…..
*Bearing IMEI.No.1/Serial No. ………………………..
*Bearing IMEI No.............................................
Make & Model No. …………………………………………………
Type of Equipment:
(Handset/laptop/Phablet/Tablet)
.
The said equipment has been stolen/lost on date ….……/….……/20……., detailed description of loss is as mentioned
below.
Detail Description of Incident:
I / we was/ were using the service of (Mobile Service Provider name)
and my 10 digit mobile
no. was ___________________________________________ I/we have already informed the service provider to bar
all the SIM services (including incoming & outgoing calls) against the aforementioned no. letter in effect of same is
attached herewith for your ready reference. I / We would hereby like to lodge a complaint for the stolen mobile and
request you to kindly assist us in finding the said mobile. As soon as the said mobile is recovered kindly inform to
me/us.
I /We would further request you to kindly let me/us know the reference no. (General diary/Daily diary number)
________________________________________ for our complaint; so that same can be used in future
correspondence.
Thanking you
Signature of the claimant/Insured
Place:
Seal & Signature of Police Station
Place:
Claim Document Checklist – (For Theft Claims)
Want to know about Claim Document Checklist –
It's pretty hard to remember what to do after the initial shock and surprise after losing your Equipment If you
are involved in such an incident, a checklist is to help ease your mind if you are involved in a loss, follow
these tips to make sure you are prepared. Please note all the following documents need to be submitted to
initiate the claim procedure with insurance company & we “UIBSPL” service provider will assist you to put
forward all your claim documents.
1) Claim Form.
2) Declaration Form.
3) Call Barring Certificate
4) Police Complaint Copy
5) Original Purchase Invoice
6) A copy of Claimant and SIM owner, photo cum Signature ID proof.
7) In case of claimant is other than purchaser, relationship proof between claimant & purchaser.
8) If the equipment is purchased by Company, a letter on companies’ letter head confirming authorized
person/user.
These documents can also be downloaded from webpage http://iphoneinsurance.euniversal.co.in
Note: Unless requested, do not send your Mobile accessories like Battery, Earphone, charger, Data cable,
Mobile Box etc. If lost or misuse, we do not undertake any responsibility.
Kindly fill all the details in true & correct manner with regards to your claim for hassle free claim experience
and process. Submit the required original documents within 15 days from the date of registration of your
claim.
Please note that your claim documents will be forwarded by our team only when it is complete in all
manners as required by Insurance Company
All original claim documents will be retained by Insurance Company & hence it is advisable to
maintain a copy for your record.
For any assistance do call us on 022 4910 7910 or send an SMS as UIBSUPPORT (Space)
IPHONEINSURANCE (Space) <your 10 digit mobile number> e.g. UIBSUPPORT )
IPHONEINSURANCE 1234567890 or write us at
[email protected] and we shall be more than happy to assist you.
___________________________________________________________________________________
Version– 2.1
All rights reserved
©Universal Insurance Brokers Services Pvt. Ltd.
Section 1 - Definitions
This document gives information about Insurer, Insured,
Beneficiary/User and Insured Equipment etc & other terms &
conditions
Proposer: Apple Certified Distributors/Partners for the benefit of
their end consumer/beneficiary, whereby customer purchase an
Insured Equipment during the Policy Period, through their Medium
Insurer: The New India Assurance Company Limited
Issuing Office: DO no - 111700, 3rd Floor, Asian Building, R.
Kamani Road, Ballard Estate, Mumbai – 400001
Beneficiary/User - Purchaser of the new equipment bundled along
with insurance. However his / her Spouse, Children & Parents can use
the equipment. Where the purchaser is a company, beneficiary/user
shall mean any representative/ employee of the company authorised
to use the Equipment
Insured Equipment: Insured Model as shown on purchase Invoice
restricted only to Apple products such as I Phone/ I Pads or Laptops
Medium: B2B Partner/ offline & online retailer of proposer only for
Apple products
Administrator/Facilitator/Coordinator: Universal Insurance
Brokers Services Private Limited (UIB) & its ancillary partner’s if
any
Cover Period: 12 month from the date of 1st purchase of Insured
Equipment by beneficiary.
Sum Insured: Declared value by Proposer / MRP or Invoice Value
whichever is lower.
Policy Period: 23rd March 2015 to 22nd March 2016.
Section 2 – The scope of cover
Provided beneficiary/user has purchased Insured Equipment and same
is mentioned in the invoice issued by Proposer medium to end
customer i.e. beneficiary/user and proposer have declared Insured
Equipment to insurer and paid appropriate premium. Insurer in the
following event to Insured Equipment will accept liability towards
repair or replacement with same or similar equipment or at their
option will arrange for payment as per policy terms and condition, if
equipment

Suffers accidental physical damage to the Insured
Equipment and/or such damage cause’s equipment to stop
working.
 Fails to work because accidentally fluid has entered its
internal circuitry, resulting into stoppage of the insured
equipment.
 Burglary including theft and housebreaking
 Stolen from a locked building/room/vehicle.
 Fire, lightening and explosion.
 Act of god perils
 Damage or theft during riot, strike & malicious damage.
Beneficiary will not be eligible for any compensation, for any loss or
damage to accessories even if forming a part of standard pack or to
any complimentary or ancillary product/s, made available.
Section 3 – Exclusions
This Insurance policy does not cover:
1. Loss, such as lost, forgotten/misplaced/left unattended,
missing, fallen and any loss under mysterious
circumstances.
2. Loss resulting from or caused by theft, or attempted theft of
insured equipment, left in unattended vehicle or room
except car of fully enclosed saloon type or room, having at
the time all the doors/windows and other opening securely
locked and properly fastened.
3. Loss due to intentional act or wilful neglect.
4. Loss arising after 12 month from date of purchase.
5. Any loss due to hire or loan of the insured equipment to a
third party or if ownership is transferred.
6. Loss arising due to unlawful act including Terrorist activity,
War, Nuclear Explosion, Radioactive Contamination,
Chemical, Biochemical, Biological, Electromagnetic, Cyber
Attack etc.
7. Any loss if the insured equipment is not connected to any
cellular network of service provider.
8. Consequential loss of any kind or description including
wear & tear, manufacturing defects etc.
9. Loss caused by incorrect storage, poor care and
maintenance, careless use, gross negligence, incorrect
installation and incorrect set-up.
10. Loss covered by supplier, dealer or factory warranty.
11. Any loss of data or software installed in the equipment.
12. Any loss arising outside the territorial limits of India.
13. Any loss which is cosmetic in nature and does not result in
to complete stoppage of/or functioning of equipment.
14. Any loss which is due to regular wear and tear and does not
result in to complete stoppage of/or functioning of
equipment and loss effecting to SIM card and/or any
ancillary product etc even if the equipment result into
complete stoppage of working.
15. Any loss prior to delivery of insured equipment, if
purchased online.
Section 4 – Compensation
Total Loss: –
Compensation for any total loss claims will be by way of NEFT or
payment to the beneficiary account by suitable mode. Maximum
liability per Insured Equipment shall be Sum Insured, subject to
excess and depreciation depending on age of insured equipment from
date of purchase at the date & time of loss.
Partial Loss: –
Compensation for any Partial Loss claims will be by way of repair or
exchange as per OEM policy to the insured equipment and
reimbursement by way of NEFT/payment to the beneficiary account
by suitable mode. Maximum liability shall be cost of repair or
exchange cost, subject to excess. If the repair or exchange cost or
maximum liability at the time of loss exceeds the total loss settlement,
insurer shall settle the claim on total loss under BER (Beyond
Economic Repair).
PTO...
If the repair value is more than the compensation payable,
beneficiary has to bear the difference between repair value and
approved amount.
Excess is minimum value which shall be deducted in each and
every claim. Excess is 5% of the claim value, or 300 rupees,
whichever is higher.
The Sum Insured or maximum liability shall be calculated as
follows by applying depreciation on the claim value only for total
loss:
Age
0 to 90days
91 to 180 days
More than 180days
Depreciation
10% of Purchase Price/SUM
INSURED
20% of Purchase Price/SUM
INSURED
50% of Purchase Price/SUM
INSURED
Maximum of 2 claims shall be addressed by the Insurer, during policy
period; subject to maximum liability or Sum Insured at the time of
loss.
Section 5 – Policy Condition
User or beneficiary agrees that:
 Take all reasonable steps to safeguard the insured
equipment.
 In the event of loss, declare/disclose all the material fact
about the incidence or event and submit salvage.
 In the event of a loss, all benefits shall be forfeited, where
there are any misrepresentations, misdescripition or non
disclosure of any material fact significant to admission of
liability and assessment of loss.
Section 6 – Claim Procedure
In the event of loss insured or beneficiary is required to do following
steps:



An immediate intimation (not later than 48 hours from the
date and time of loss) about loss should be given to insurer
or Universal Insurance Brokers (UIB) on
022 – 4910 7910.
All claim related documents or correspondence need to be
submitted to UIB and all such documents or correspondence
should reach UIB not later than 15 calendar days from the
date and time of the event of loss.
Theft Category –
The event should be immediately (not later than 48 hours
from the date and time of loss) reported to the nearest police
authorities and police acknowledgment/receipt to be
furnished.
The event will have to be simultaneously notified to the
cellular network service provider not later than 48 hours
from the date and time of loss and a written
acknowledgment on confirmation of barring of SIM services
from network service provider to be furnished.
Damage Category –
 The event needs to be notified to UIB with proximate cause
or reason of loss & obtain service estimate towards damage.
 Do not get the damaged insured equipment repaired unless
intimated over helpline of UIB & further authorized by
insurer.
Section 7 – Contact points for Claims
All claim related queries and submission of claim document/s or
correspondence should be directed to Universal Insurance
Brokers Services Private Limited by calling on
022 – 4910 7910 or by sending an SMS as “UIBSUPPORT (space)
IPHONEINSURANCE (space) <mobile number> (on which
customer wish to get reply from UIB) to 56767
E.g. UIBSUPPORT IPHONEINSURANCE 1234567890
All claim related documents or correspondence need to be
submitted by the user/beneficiary to Universal Insurance Brokers
Services Pvt. Ltd (UIB) in Duplicate i.e. Original claim
document/s with one additional photo copy of all original claim
document/s.
Note: Original Documents shall be retained by Insurer at the time
of claim and shall not be returned to the insured/claimant.
For claim guidance or assistance or claim related queries or
information related to policy, beneficiary can contact
Insurer/UIB. Insured/Beneficiary can inform about the claim i.e.
claim intimation, know their claim status and also get all other
relevant information by calling on 022 – 4910 7910 or writing an
email at [email protected] or by sending
an SMS as “UIBSUPPORT (space) IPHONEINSURANCE (space)
<mobile number> (on which customer wish to get reply from UIB) on
56767
E.g. UIBSUPPORT IPHONEINSURANCE 1234567890 or log on
http://iphoneinsurance.euniversal.co.in
The Insured may refer http://iphoneinsurance.euniversal.co.in to
view or download for all insurance claims related documents.
This insurance policy is valid only if make and model of the
insured equipment is Apple
Insurance is subject matter of solicitation.